Understanding the Difference Between OCD and BFRBs

Recognizing the distinction between OCD and BFRBs matters for diagnosis and treatment.

• Both OCD and BFRBs involve repetitive behaviors that can feel hard to stop.

• OCD and BFRBs can overlap, but they are separate conditions with differing treatment approaches.

• Getting the right diagnosis is the first step toward the right kind of help.

Body-focused repetitive behaviors (BFRBs) and obsessive-compulsive disorder (OCD) are often confused. Both conditions can cause significant distress and impairment to daily functioning, and both often involve repetitive actions that feel difficult or impossible to stop.

Yet there are important differences in their underlying mechanisms, functions, and treatments. Let’s explore what connects these two and what sets them apart.

The Overlap: Why They're Sometimes Confused

1. Repetitive behaviors that feel compulsive

At first glance, both BFRBs and OCD involve behaviors that are repeated and hard to control. Someone may repeatedly pull out hair (trichotillomania), pick at skin (excoriation disorder), or check the locks on the door dozens of times (OCD). This can understandably seem similar to an outside observer.

2. Tension and relief cycles

Many people with BFRBs or OCD describe feeling a build-up of internal tension, discomfort, or distress that is only relieved by performing the behavior. In both cases, the action may offer temporary relief, but often at the cost of longer-term distress or impairment.

3. Co-occurrence

It’s not uncommon for individuals to experience both OCD and a BFRB. For example, a person with contamination-related OCD, marked by fears of illness and cleaning rituals, may also struggle with compulsive skin picking.

4. Neurobiological overlap

Emerging research suggests that there is shared brain circuitry involved in OCD and BFRBs, particularly in regions related to habit formation, impulse control, and emotional regulation.

The Distinctions: Why They Are Distinctly Different

1. Diagnostic categories

Though both are included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR; 2022) under the category of Obsessive-Compulsive and Related Disorders, BFRBs like trichotillomania and excoriation disorder are distinct diagnoses classified within that grouping of disorders.

2. Awareness and automaticity

It’s common for people with BFRBs to engage in behaviors outside of full awareness. They may find themselves pulling or picking automatically, often while distracted or under-stimulated, only noticing after they have been engaging in the behavior for a period of time. OCD compulsions, by contrast, are more deliberate and purposeful and are often accompanied by significant distress in the moment.

3. Nature of thoughts and function of the behavior

OCD is characterized by obsessions (i.e., intrusive, unwanted thoughts, images, or urges that generate significant anxiety) and compulsions (i.e., mental or behavioral actions performed to reduce that anxiety or prevent a feared outcome). BFRBs, in contrast, are not typically driven by obsessive fears. Instead, they are often preceded by a physical urge, sensory discomfort, or an emotional state, such as tension or boredom.

This doesn’t mean intrusive thoughts never occur with BFRBs, because they can. For example, someone with skin picking disorder might notice a bump and think, “This shouldn’t be here” or “If I pick this, it will heal faster.”

The difference lies in the function of the behavior: In OCD, the thought is linked to fear, and the behavior is carried out to prevent harm or reduce anxiety. In BFRBs, the thought may prompt the behavior, but it is not about averting danger. Instead, the behavior is driven by urges, sensations, or the search for relief.

4. Nature of the behaviors

OCD compulsions are usually carried out according to rigid rules or rituals. For example, someone might feel they must wash their hands a specific number of times, check the stove in a certain sequence, or repeat a phrase until it feels “just right.” These rules provide a sense of certainty or safety in the face of anxiety.

BFRBs, by contrast, are not typically rule-bound. Hair pulling, skin picking, or nail biting usually don’t follow a strict pattern or sequence. And, if the sequence is carried out more flexibly, there is no distress associated with the way in which it must be carried out in order to provide relief.

5. How the symptoms feel in the moment

BFRBs are often at least partly ego-syntonic, meaning they can feel consistent with an individual's desires or provide some short-term satisfaction. For example, pulling hair or picking skin may bring a sense of relief, soothing, or even pleasure, even if those feelings are followed by guilt, frustration, or shame.

In contrast, OCD compulsions are usually ego-dystonic, meaning they feel unwanted, distressing, and out of alignment with what the person actually wants. Someone with OCD may wash their hands for hours, not because it feels good, but because they feel they have to in order to try to get rid of overwhelming anxiety or prevent something terrible from happening.

This distinction is important: BFRBs tend to persist, in part, because they provide short-term relief or reward, while OCD compulsions are fueled by fear and anxiety. As a result, the two conditions require very different treatment approaches.

6. Treatment approach

While cognitive behavioral therapy (CBT) is foundational for both, the specific interventions differ. OCD is most effectively treated with exposure and response prevention (ERP). Although ERP may be a useful component of an evidence-based treatment plan for BFRBs, a more comprehensive behavioral treatment approach is considered the standard of care, including the integration of treatment components (integrative behavioral therapies), such as traditional CBT, habit reversal training (HRT), comprehensive behavioral treatment (ComB), acceptance and commitment therapy (ACT), mindfulness practices, and dialectical behavioral therapy (DBT) skills.

While serotonergic agents, most commonly selective serotonin reuptake inhibitors (SSRIs), are often effective in reducing symptoms of OCD, their benefits for BFRBs are far less consistent. In fact, there are currently no FDA-approved medications specifically for the treatment of BFRBs, though medications may still play a role in managing co-occurring conditions that can influence BFRB symptoms.

Why Understanding the Difference Between OCD and BFRBs Matters

Although OCD and BFRBs share similarities, they are fundamentally different in what drives them, how they are experienced, and how they respond to treatment. Mistaking one for the other can delay effective care and leave individuals feeling misunderstood or unsupported.

Recognizing these distinctions not only guides people toward proper care and resources but also reduces stigma and self-blame. Accurate diagnosis and evidence-based treatment can make a profound difference, offering individuals the tools they need to reduce symptoms and improve quality of life.

Marla Deibler, Psy.D., ABPP, - Welcome - Blog -